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Extreme Measures: Finding a Better Path to the End of Life Hardcover – February 21, 2017

4.7 4.7 out of 5 stars 302 ratings
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For readers of Being Mortal and Modern Death, an ICU and Palliative Care specialist offers a framework for a better way to exit life that will change our medical culture at the deepest level


In medical school, no one teaches you how to let a patient die.

Jessica Zitter became a doctor because she wanted to be a hero. She elected to specialize in critical care—to become an ICU physician—and imagined herself swooping in to rescue patients from the brink of death. But then during her first code she found herself cracking the ribs of a patient so old and frail it was unimaginable he would ever come back to life. She began to question her choice.

Extreme Measures charts Zitter’s journey from wanting to be one kind of hero to becoming another—a doctor who prioritizes the patient’s values and preferences in an environment where the default choice is the extreme use of technology. In our current medical culture, the old and the ill are put on what she terms the End-of-Life  Conveyor belt. They are intubated, catheterized, and even shelved away in care facilities to suffer their final days alone, confused, and often in pain. In her work Zitter has learned what patients fear more than death itself: the prospect of dying badly. She builds bridges between patients and caregivers, formulates plans to allay patients’ pain and anxiety, and enlists the support of loved ones so that life can end well, even beautifully.

Filled with rich patient stories that make a compelling medical narrative, Extreme Measures enlarges the national conversation as it thoughtfully and compassionately examines an experience that defines being human.
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  1. Print length
    352 pages
  2. Language
    English
  3. Publisher
    Avery
  4. Publication date
    February 21, 2017
  5. Dimensions
    6.3 x 1.2 x 9.4 inches
  6. ISBN-10
    1101982551
  7. ISBN-13
    978-1101982556
  8. See all details
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Editorial Reviews

Review

"Like Atul Gawande's Being Mortal, Zitter's book shows how knowing when do to nothing is as vital to being a good doctor as knowing when do to everything."
—New York Times Book Review

“Jessica here reveals a fuller truth of how the end-of-life plays out within our healthcare system. There’s nothing easy in these pages, but plenty to learn from, cautions to absorb, and material for creating a better way.” 
—BJ Miller, MD, Assistant Clinical Professor of Medicine at UCSF

"Part memoir, part exposé, this book is an insider's view of intensive care in America and its impact on how we die, written by a physician uniquely positioned to examine end-of-life care. Dr. Jessica Zitter’s wisdom derives from a career whose trajectory – she specializes in both ICU and palliative medicine – models a rethinking of care for the dying. Her book is a trenchant critique and a clarion call for end-of-life care that aligns with what each patient values most."
—Lucy Kalanithi, MD

"Dr. Zitter has pulled back the curtain on the needless suffering undergone by the dying in Intensive Care. Honest about her own uncertainties, mistakes and limitations, she spares no one, not even herself. The average person will learn much about the pitfalls of navigating the strange subculture of medicine close to the end of life.”
—Katy Butler, author of Knocking on Heaven's Door: The Path to a Better Way of Death and A Good End of Life: a Practical Guide
 
“America's healthcare system inadvertently makes things worse for dying patients and their families. This situation calls for Extreme Measures – and this book is the remedy we need. Dr. Zitter’s guidance is an elixir of medical sophistication, practical savvy, and timeless soulfulness.  She writes with the clinical mastery of an intensivist and the personal sensitivity of a trusted friend.”
—Ira Byock, MD, author of The Best Care Possible
 
"Required reading for every young medical student and every family member wondering how to help the people they love live well to the end." 
—Ellen Goodman, founder of The Conversation Project
 
"With compassion, intelligence, and a rare expertise, Jessica Zitter shines a light on some of the most difficult issues we face in our lives." 
—Angelo Volandes, MD, author of The Conversation: A Revolutionary Plan for End-of-Life Care
 
"You wouldn't take a trip to a foreign country without learning as much as you could about its rituals, its culture, and its landscape. The ICU, a place many of us will pass through at least once in our lives, is as foreign as it gets.  Thus Dr. Zitter provides an essential illumination for her fellow humans."
—Diane E. Meier, MD.  Director, Center to Advance Palliative Care
 
"A stunning portrait of the ways decisions in the intensive care unit shape the way we live—and die—now.  Whether we live with illness, love someone who is facing these decisions, or care for them professionally, Dr. Zitter has written a call to action that none of us can ignore.”
—Anthony Back MD, author of Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope
 
“Extreme Measures provides a gripping and intimate tour of the experiences and dilemmas  physicians, patients and families  face dealing with terminal illness in the modern ICU. A tour de force for those seeking to better understand and improve care of patients and families at end of life."
—James Mittelberger MD, MPH, FACP, FAAHPM, Optum Director and Chief Medical Officer, Center for Palliative Care and Supportive Care

"Clarity and compassion unite in this touching and convincing new conversation on comfortable, patient-centered end-of-life care."
—Kirkus Reviews 

About the Author

Jessica Nutik Zitter, M.D., MPH, is an expert on the medical experience of death and dying. She attended Stanford University and Case Western Reserve Medical School, and completed her residency in internal medicine at the Brigham and Women’s Hospital in Boston. She was a fellow in pulmonary and critical care medicine at the University of California San Francisco. Zitter is double-boarded in the two specialties of pulmonary/critical care medicine and palliative care medicine—a rare combination. She writes for The New York Times, The Huffington Post, Pacific Standard, The Atlantic, and Journal of Palliative Medicine, and is featured in Extremis, an Oscar-nominated Netflix documentary about end-of-life decision-making in an ICU.

Product details

  • Publisher ‏ : ‎ Avery; 1st edition (February 21, 2017)
  • Language ‏ : ‎ English
  • Hardcover ‏ : ‎ 352 pages
  • ISBN-10 ‏ : ‎ 1101982551
  • ISBN-13 ‏ : ‎ 978-1101982556
  • Item Weight ‏ : ‎ 1.19 pounds
  • Dimensions ‏ : ‎ 6.3 x 1.2 x 9.4 inches
  • Customer Reviews:
    4.7 4.7 out of 5 stars 302 ratings

About the author

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Jessica Nutik Zitter M.D.

Jessica Nutik Zitter M.D.

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After two decades of caring for critically ill patients, Jessica Nutik Zitter, MD, MPH is a strong advocate for a new approach to caring for the dying. She practices the unusual combination of ICU and palliative care medicine at Highland Hospital, the county hospital in Oakland, California. Having herself participated in the default and indiscriminate use of technology with the dying and witnessed the resultant suffering, Dr. Zitter has come to view this situation as a public health crisis. She is committed to reorienting our care of the dying to a more collaborative process whereby the patient, rather than her organ or disease, is the primary focus of care.

Dr. Zitter’s first book, Extreme Measures, Finding A Better Path to the End of Life, (Avery, an imprint of Penguin-Random House, Spring 2017), offers an insider’s view of intensive care in America and its impact on how we die. Her essays and articles have appeared in the New York Times, The Atlantic, the Huffington Post, the Journal of the American Medical Association, and other publications. In 2005 she co-founded Vital Decisions, a telephone counseling service for patients with life-limiting illnesses.

Her work is featured in the Oscar nominated documentary, “Extremis,” available on Netflix. This vérité film follows Jessica, her team and several patients and their families in the intensive care unit at Highland Hospital.

Dr. Zitter attended Stanford University and Case Western Reserve University Medical School and earned her Master of Public Health at the University of California, Berkeley. Her medical training includes an Internal Medicine residency at Harvard’s Brigham and Women’s Hospital in Boston and a fellowship in Pulmonary/Critical Care at the University of California, San Francisco.

More information and relevant resources are available at jessicazitter.com

Customer reviews

4.7 out of 5 stars
4.7 out of 5
302 global ratings
this is not only an interesting book, it is an important book
5 Stars
this is not only an interesting book, it is an important book
Who'd want to die in an ICU? Not many of us. Dr. Zitter is a rare hybrid--an ICU physician also trained in palliative care for dying patients. Some say this is an oxymoron she writes. In a well-written book, she's chosen cases that illustrate, case by case, the the incredible variety of things that can get screwed up by the innate avoidance by all of us, patients and medical staff, who avoid talking about death, especially at times when the subject must be talked about. And she shows, not tells, us how to go about these situations, not only in general, but also in all of the specifics.This book is accessible, interesting, dramatic, really not macabre, and espouses the notion that death is an inevitable part of all of our lives. Obvious, but the cases illustrate the extraordinary effort we use to avoid the obvious. That brings to mind another book on the subject with a great title, A Beginner's Guide to the End. We beginners thank you, Dr. Z.
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Top reviews from the United States

Kathy
5.0 out of 5 stars Well-written, fast paced
Reviewed in the United States on April 9, 2023
Verified Purchase
I am currently a Hospice patient. Have read over 30 books on end of life issues and this is one of the best.. I also happen to be. a retired physician.

Of all the books I read, this author truly gets both sides of making a decision to enter hospice. Book would be helpful for the patient a well as for loved ones and caregivers. Also excellent for the medical profession as a whole.

Highly recommended. Author is physician herself and understands when to call it quits.

Author is a go--getter and quite revealing of some of her own mis-calls.

Well worth reading.
7 people found this helpful
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H. W. Taeusch
5.0 out of 5 stars this is not only an interesting book, it is an important book
Reviewed in the United States on August 15, 2021
Verified Purchase
Who'd want to die in an ICU? Not many of us. Dr. Zitter is a rare hybrid--an ICU physician also trained in palliative care for dying patients. Some say this is an oxymoron she writes. In a well-written book, she's chosen cases that illustrate, case by case, the the incredible variety of things that can get screwed up by the innate avoidance by all of us, patients and medical staff, who avoid talking about death, especially at times when the subject must be talked about. And she shows, not tells, us how to go about these situations, not only in general, but also in all of the specifics.

This book is accessible, interesting, dramatic, really not macabre, and espouses the notion that death is an inevitable part of all of our lives. Obvious, but the cases illustrate the extraordinary effort we use to avoid the obvious. That brings to mind another book on the subject with a great title, A Beginner's Guide to the End. We beginners thank you, Dr. Z.
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H. W. Taeusch
5.0 out of 5 stars this is not only an interesting book, it is an important book
Reviewed in the United States on August 15, 2021
Who'd want to die in an ICU? Not many of us. Dr. Zitter is a rare hybrid--an ICU physician also trained in palliative care for dying patients. Some say this is an oxymoron she writes. In a well-written book, she's chosen cases that illustrate, case by case, the the incredible variety of things that can get screwed up by the innate avoidance by all of us, patients and medical staff, who avoid talking about death, especially at times when the subject must be talked about. And she shows, not tells, us how to go about these situations, not only in general, but also in all of the specifics.

This book is accessible, interesting, dramatic, really not macabre, and espouses the notion that death is an inevitable part of all of our lives. Obvious, but the cases illustrate the extraordinary effort we use to avoid the obvious. That brings to mind another book on the subject with a great title, A Beginner's Guide to the End. We beginners thank you, Dr. Z.
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6 people found this helpful
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Catherine M. Stewart
5.0 out of 5 stars A must read for everyone because everyone dies
Reviewed in the United States on December 13, 2022
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I wish there was a way for everyone facing death—and we all will—to be cared for by a doctor as compassionate and caring, authentic and forthright as Dr. Zitter. I truly hope that her vision for quality of life at the end transforms our medicalized prolongation of life for its own sake. Not only is it economically unsustainable but it inflicts unnecessary suffering, separation, and isolation on patients and their loved ones. By bravely helping gravely I’ll patients and their families understand their condition and options, she gives them the gift of choosing to live the best life they can to the end. Her courage in the face of intense pressure from her profession is astonishing. Thank you, Dr. Zitter.
3 people found this helpful
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Gidget's Mom
4.0 out of 5 stars Something we all need to know.
Reviewed in the United States on March 11, 2017
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I am only giving 4 stars, because I almost stopped reading at the mention of George Soros. This is not a political subject, and I am still wondering why his inclusion was necessary. Otherwise, a very good book.
7 people found this helpful
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Bruce Vermazen
5.0 out of 5 stars Pages missing
Reviewed in the United States on May 23, 2022
Verified Purchase
The book is engrossing and informative, but it is supposed to be about 330 pages long, and the paperback copy I received ends (in mid-sentence) at page 306. The notes and index are missing, along with a short chapter called "Resources" that would be useful to a reader (like myself) who wanted to follow up on the author's recommendations. So, before you order this book, be sure to contact the seller to be sure that pp. 307–330 are included. I didn't discover the defect until after the 30-day return period.
2 people found this helpful
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5.0 out of 5 stars Extreme Measures is a exceptional book. Dr. Zitter ...
Reviewed in the United States on March 1, 2017
Verified Purchase
Extreme Measures is a exceptional book. Dr. Zitter takes on an extremely tough subject and delivers a highly readable, engaging and invaluable read. The book captured me immediately, with Dr. Zitter's vivid account of her personal history, her portrait of her self as a young child enthralled with her father and grandfathers' medical practices. From there she moves on to her career history and how she ended up as an intensivist and palliative care doctor. The vignettes of end of life stories that make up the heart of the book are highly engaging and meaningful--each one is unique and compelling, illustrating the different paths that lead to the patients' end of life decisions made by the patients, doctors and family members. The book makes a compelling argument for all of us to document our own end of life "to do and not to do" lists, and in doing so performs a valuable public service.
7 people found this helpful
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Null
5.0 out of 5 stars One Fewer Reason to dread dying
Reviewed in the United States on September 7, 2017
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I had placed this book on my wish list. I was sure I should read it. I was not sure I wanted to read it. Without divulging my own history, allow me to say that I am a lifelong skeptic in so far as the value of medical treatment for any but the most common human conditions. At the same time I have the highest respect for the sacrifices made by nurses and physicians. In the end, I clicked on the wrong button and ended up with a complete copy in my Kindle.

The first time I attempted to read it the early history of author and ancestors caused buyers remorse. The second time I started with chapter 2 and was immediately engrossed. That was because it validated nearly all my firmly held convictions about just how badly so many people end their lives in the ICU. Please consider that living in Brazil and traveling in much of latin america opened my eyes to pain, suffering, and death many years ago. Inflicting it in the ICU seems much worse, however.

My parents are deceased. In the ten years following the death of one, management of death had improved remarkably for the other. With the passage of death with dignity here in Colorado, I see a glimmer of hope that death may come to be viewed as merely the end of life. For many it will merely become a release without the fears of anguish so frequently dispensed in the ICU.
25 people found this helpful
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newtonian
5.0 out of 5 stars A nuanced and beautifully-written exploration of the complexities of end-of-life care
Reviewed in the United States on February 27, 2017
Verified Purchase
Outstanding! Extreme Measures arrived at my door on Friday, I started it Saturday evening, and finished it Sunday afternoon. Replete with personal anecdotes and stories from a career that has spanned more than 20 years, Dr. Zitter succeeds in exploring and revealing the complexities, moral and ethical, of end-of-life care in twenty-first century America. As she so thoughtfully and compassionately points out, striving for a good death is no less important than fiercely fighting to help those who may recover, once the point has been reached where cure is no longer possible and the costs of delaying the inevitable are measured in dehumanizing and often unbearable suffering for patient and family alike.

Dr. Zitter is a very gifted writer, but more importantly: She shows herself to be the physician any of us would want caring for ourselves or for our loved ones in our hour of need.
19 people found this helpful
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Top reviews from other countries

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C. Davis
5.0 out of 5 stars Thought provoking
Reviewed in the United Kingdom on September 16, 2021
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I am firmly in the `do not resuscitate' camp and would hate to spend years hooked up to machines, unable to speak or move or participate in life at even a basic level. This books highlights the fact that, if you don't clearly leave a directive, doctors are obliged to keep you alive even if you can no longer achieve anything. This is an American book so the legal information at the end is inapplicable to the UK. As such, I will investigate how to leave a directive with my medical notes so that I am not kept alive artificially when my body is ready to give up!
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Suzel Brunel
5.0 out of 5 stars Que se passe-t-il dans les coulisses des ICU ?
Reviewed in Canada on January 3, 2020
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L'auteur, médecin spécialiste en médecine de fin de vie, décrit avec intelligence, empathie et sensibilité les coulisses de cet univers de spécialistes qui se soucient davantage de leur propre image que du bien-être de leurs patients mourants, confus, hésitants. Un excellent ouvrage pour tous ceux et celles qui vivent avec ces questions si délicates.
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AM
5.0 out of 5 stars Be Informed!
Reviewed in Canada on September 29, 2017
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A must read by everyone; know what the typical medical practices are at the end of life and what you or your loved one would want done; my preference is a comfortable natural death; not in the ICU at the hospital; but you need to know how to handle it for yourself (tell your loved ones) or for your loved one (share with your family to get concensus).
One person found this helpful
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Ruth Freese
5.0 out of 5 stars Read this book
Reviewed in Canada on May 21, 2017
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This book is excellent and informative. It's certainly made me consider issues about the end of life which I had not been aware of. I strongly urge anyone with a serious illness or with a relative with a serious illness to read it.
3 people found this helpful
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Arlie
5.0 out of 5 stars Five Stars
Reviewed in Canada on May 15, 2017
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Great, eye-opening book regarding end of life decisions. Prolonging life sometimes results in needless suffering.
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